Medical form

PATIENT REGISTRATION INFORMATION

Date

Date of Birth

Patient First Name

Middle Initial

Patient Last Name

PLEASE ANSWER ALL QUESTIONS BY CHECKING YES OR NO.
All responses are kept confidential.

1. Are you in good health?

Yes No

2. Has there been any change in your general health in the past year?

Yes No

3. Date of last physical exam

4. Are you now under a physician’s care for a particular problem?

Yes No

5. Have you had any serious illnesses, operation, or hospitalizations?

Yes No

If so, describe:

6. Do you have or have you ever had:

A. Rheumatic fever or rheumatic heart disease?

Yes No

B. Congenital heart disease?

Yes No

C. Cardiovascular disease (heart attack, heart murmur, coronary artery disease, angina, high blood pressure, stroke, palpitations, heart surgery, pacemaker)?

Yes No

D. Lung disease (asthma, emphysema, chronic cough, pneumonia, tuberculosis, shortness of breath, chest pain, severe coughing)?

Yes No

E. Neurologic-psychiatric disorders (convulsions, epilepsy, seizures, fainting, psychiatric treatment, dizziness, nervous disorder or breakdown)?

Yes No

F. Blood disease (anemia, bleeding tendency, blood transfusion, do you bruise easily)?

Yes No

G. Liver Disease (jaundice, hepatitis)?

Yes No

H. Kidney Disease?

Yes No

I. Diabetes?

Yes No

J. Thyroid disease (goiter)?

Yes No

K. Arthritis?

Yes No

L. Stomach ulcers or colitis?

Yes No

M. Glaucoma?

Yes No

N. Frequent or recurring mouth sores?

Yes No

O. Implants placed anywhere in your body?

Yes No

(heart valve, hip, knee)?

Yes No

P. Radiation (x-ray) treatment for cancer?

Yes No

Q. Clicking or popping of jaw joint, pain near ear, difficulty opening mouth, grind or clench teeth?

Yes No

R. Sinus or nasal problems?

Yes No

S. Any disease, drugs or transplant operation that has depleted your immune system?

Yes No

T. Recurrent infections of any kind?

Yes No

U. Sensitivity to motion sickness?

Yes No

7. Are you using or taking any of the following:

A. Antibiotics or sulfa drugs?

Yes No

B. Anticoagulants (blood thinners)?

Yes No

C. High blood pressure medicine?

Yes No

D. Steroids (Cortisone, etc)?

Yes No

E. Tranquilizers (Valium, etc)?

Yes No

F. Insulin, Diabenese, or similar drug?

Yes No

G. Digitalis, Inderal Nitroglycerin or other heart medicine?

Yes No

H. Aspirin?

Yes No

How much daily?

I. Marijuana or other “street” drugs?

Yes No

J. WOMEN Birth control pill?

Yes No

K. Bisphosphonate for cancer or osteoporosis?

Yes No

L. Any other regular mediations, pills or drugs?

Yes No

Other

8. Are you allergic or had bad reaction to:

A. Local anesthetic (Novocaine, etc)?

Yes No

B. Penicillin or other antibiotics?

Yes No

C. Barbiturates, sedatives, etc?

Yes No

D. Aspirin?

Yes No

E. Codeine or other pain killers?

Yes No

F. Other allergies or reactions?

Yes No

If yes, please list:

G. Problems with general anesthesia or sedation?

Yes No

9. Have you ever sought professional care for drug abuse, alcoholism or emotional disorders?

Yes No

10. WOMEN Are you pregnant or planning pregnancy?

Yes No

11. Do you have any other disease, condition or problem not listed above, that you think the doctors should know?

Yes No

12. Do you wish to talk with the doctor privately about anything?

Yes No

Form Completion

I understand the importance of a truthful health history to assist the doctor in providing the best care possible. I have had the opportunity to discuss my health history with my doctor.

Signature of Person Completing Health History

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PATIENT REGISTRATION INFORMATION

Form Completion

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